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School of Nursing and Midwifery Challenges in mental health care.

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Presentation on theme: "School of Nursing and Midwifery Challenges in mental health care."— Presentation transcript:

1 School of Nursing and Midwifery Challenges in mental health care

2 School of Nursing and Midwifery Physical health and severe mental illness: time for action Richard Gray RN PhD Adjunct Professor of Mental Health Nursing NUI Galway, Ireland e: w:

3 School of Nursing and Midwifery “Look to your health; and if you have it, praise God, and value it…” IZAAK WALTON

4 School of Nursing and Midwifery Why do research?

5 School of Nursing and Midwifery Why do research? To enhance patients quality of life, health and experience of healthcare IMPACT Research without impact is pointless

6 School of Nursing and Midwifery

7 How much younger will you die if you have schizophrenia?

8 School of Nursing and Midwifery Life expectancy in patients with SMI Life expectancy in the UK at birth –81.5 year for girls –77.2 years for boys Newman and Bland (1991) estimated a 20% reduction in life expectancy in a cohort of 3,623 in Canada Systematic review of population based studies (1) –SMR* of 2.50 (95% confidence interval, ) years of lost life –Early 60s for women –Late 50s for men * SMR in epidemiology is the ratio of observed deaths to expected deaths. SMR is quoted as a ratio. 1.0 means the number of observed deaths equals the number of expected cases. If higher than 1.0, then there is a higher number of deaths than is expected 1. Arch Gen Psychiatry. 2007;64(10):

9 School of Nursing and Midwifery What is the major cause of death for people with schizophrenia?

10 School of Nursing and Midwifery Suicide 4 in 10 attempt suicide 1 in 10 will commit suicide –SMR for Suicide in SMI is (12.86) (1) More than 60% of premature deaths are not directly related to suicide 1. Arch Gen Psychiatry. 2007;64(10):

11 School of Nursing and Midwifery What is the major cause of death for people with schizophrenia?

12 School of Nursing and Midwifery Physical health of patients with SMI The biggest killer is cardio-vascular disease (CVD) (1) –Most of the major causes-of death categories were found to be elevated in people with schizophrenia (2) –The SMRs for all-cause mortality have increased during recent decades (2) Most psychiatric patients have a co-morbid medical illness (2) Many illnesses go undiagnosed (2) Patient group do not volunteer complaints readily (2) 1. Robson D. and Gray R. (2006) Int J Nursing Studies 2. Arch Gen Psychiatry. 2007;64(10):

13 School of Nursing and Midwifery Why is life expectancy getting worse?

14 School of Nursing and Midwifery It’s the nasty drugs we give them…

15 School of Nursing and Midwifery Mean change in weight with antipsychotics *4–6 week pooled data (Marder et al. Schizophr Res. 2003;1;61:123-36; †6-week data adapted from Jones et al. ACNP; Allison et al. Am J Psychiatry. 1999;156: Estimated Weight Change at 10 Weeks on “Standard” Dose Haloperidol Risperidone Olanzapine Clozapine Placebo Fluphenazine Ziprasidone Chlorpromazine Thioridazine Quetiapine Aripiprazole † * Weight Change (Kg)

16 School of Nursing and Midwifery Medication is good for you… …If you have schizophrenia/bipolar illness (or depression)

17 School of Nursing and Midwifery

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19 Why is life expectancy getting worse? Cardiovascular disease is caused by obesity –I observe (in practice) that people with SMI are overweight! What is the prevalence of obesity in patients with SMI?

20 School of Nursing and Midwifery Body mass index and prevalence of obesity in a English cohort of patients with severe mental illness Running header: BMI and Obesity in Schizophrenia Donna Eldridge (1), Nicky Dawber (1), Louise Swift (2), Richard Gray (2) 1. Kent and Medway NHS & Social Care Partnership Trust 2. University of East Anglia, Norwich, NR4 7TJ

21 School of Nursing and Midwifery BMI and obesity in SMI Prospective Conducted in a mental health service in Kent, England Serves a population of 1.6 million Health checks performed by a mental health nurse who had had three days physical health training –Demographic information, prescribed medication, lifestyle factors, weight, height, laboratory tests Recruited 497 patients Eldridge et al (in prep) BMI and Obesity in Schizophrenia

22 School of Nursing and Midwifery Average BMI=30.0

23 School of Nursing and Midwifery Prevalence of obesity in men (n=272) Eldridge et al (in prep) BMI and Obesity in Schizophrenia

24 School of Nursing and Midwifery Prevalence of obesity in women (n=225) Eldridge et al (in prep) BMI and Obesity in Schizophrenia

25 School of Nursing and Midwifery Why is obesity so prevalent in patients with SMI?

26 School of Nursing and Midwifery It’s the nasty drugs we give them (again)…

27 School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia BMI category by psychotropic medication

28 School of Nursing and Midwifery Eldridge et al (in prep) BMI and Obesity in Schizophrenia BMI category by psychotropic medication Mean bmi; no medication=25, any medication=30, p<.05

29 School of Nursing and Midwifery What factors predict obesity? Multivariate analysis –Final model had four factors that explained 17% of the variance 1.Prescribed antipsychotic medication 2.Did not smoke cigarettes 3.Poor quality diet 4.Where they lived (patients less likely to be obese if they were homeless or in hospital) i.e. Patients with the lowest BMI were not taking medication, smoking cigarettes, homeless, but eating a healthy diet Eldridge et al (in prep) BMI and Obesity in Schizophrenia

30 School of Nursing and Midwifery What factors predict obesity? Multivariate analysis –Final model had four factors that explained 17% of the variance 1.Prescribed antipsychotic medication 2.Did not smoke cigarettes 3.Poor quality diet 4.Where they lived (patients less likely to be obese if the were homeless or in hospital) Eldridge et al (in prep) BMI and Obesity in Schizophrenia

31 School of Nursing and Midwifery Prevalence of other lifestyle behaviours 51% had an unhealthy diet –High in fat, <5 portions of fruit and veg a day, high in calories 44% took no regular activity 58% smoked –Many motivated to quit –>85% reported in other epidemiological studies –In 2003, 26% of British adults aged 16+ smoked cigarettes, (28% of men and 24% of women) compared with 45% in The majority claimed that they did not drink alcohol or use illicit drugs Big issue about the accuracy of reporting

32 School of Nursing and Midwifery A quick word about sex

33 School of Nursing and Midwifery What are we going to do about? Options 1.SEP (somebody else's problem - primary care) 2.Create a new service 3.Enhance the practice of secondary care mental health workers

34 School of Nursing and Midwifery What do mental health nurses think about physical health?

35 School of Nursing and Midwifery What are nurses views about physical health? Survey of 600 Nurses in the South London and Maudsley NHS Trust 99% thought that promoting good physical health was part of their role 84% thought that mental health nurses need to take responsibility for the physical health care of clients with serious mental illnesses Robson D. (in prep) Survey of mental health nurses

36 School of Nursing and Midwifery Physical health survey 78% feel that their current workload is a barrier to promoting physical health Evidence of lack of knowledge and skills – Want more training on: Giving nutritional advice (78%) Helping clients stop smoking (68%) – 74% thought mental health nurses should be more skilled at managing patients with diabetes These barriers can be addressed through: –Opportunity cost (or what do you not do) –Training –Clinical leadership Robson D. (in prep) Survey of mental health nurses

37 School of Nursing and Midwifery How good are we at monitoring physical wellbeing?

38 School of Nursing and Midwifery Metabolic screening is below recommended levels Screening of 4 aspects of metabolic syndrome in the total national sample (n=1966)Barnes et al. Schizophr Bull 2007;33: % patients screened Fewer than 2 in 10 patients are screened for obesity

39 School of Nursing and Midwifery Bells and whistles… The Wellbeing support programme

40 School of Nursing and Midwifery Addressing physical health: the WellBeing support programme

41 School of Nursing and Midwifery The WellBeing support programme Two year programme Six formal sessions with a nurse advisor Nurse advisors trained by physical health experts Performance managed Funded by industry –An add on to routine care

42 School of Nursing and Midwifery Wellbeing support Step 1: Generating a register of SMI patients and inviting them to participate in the WSP Step 2: First face-to-face Well-Being Session where physical health (blood pressure, pulse, weight and height) lifestyle factors (diet, physical activity, smoking status) and antipsychotic side effects (LUNSERS; Day et al 1995) were measured Step 3: Results of measures taken in session 1 were fed back to patients at a second face- to-face session. Blood tests (random blood glucose, thyroid function, liver function, serum prolactin, lipid screen) were performed during this meeting Step 4: Patients were referred by the practitioner to one or more of the following a weight management or physical activity group; primary care or specialist doctor for additional physical health care; medication review by prescribing clinician Step 5: Two follow-up face-to-face sessions to evaluate programme and complete follow- up measures (as in step 1 and 2) 1. Smith S. (2007) International Journal of Clinical practice

43 School of Nursing and Midwifery The WellBeing support programme 966 patients enrolled across seven demonstration sites 80% completed the programme Significant improvements in –Physical activity –Smoking –Diet No change in patients BMI –Maintenance of BMI reported as a positive outcome Programme recommended by English DH Eldridge et al (under review)

44 School of Nursing and Midwifery WellBeing in the hands of the NHS Industry… ‘Wellbeing no longer fits with our strategy’ –Nurse advisors withdrawn from practice The NHS… ‘it works let’s change it’ –One year (not two year) programme –Four (not six) formal sessions with mental health practitioner Practitioners attend a three day training course facilitated by a ‘WellBeing nurse advisor’ –Part of routine care (not an add on service) Does it still benefit patients? Eldridge et al (under review)

45 School of Nursing and Midwifery WellBeing in Kent… Started in 2006 Evaluation undertaken at the end of practitioners had attended training 754 patients enrolled on the programme Baseline and one year follow-up data on –Cardiovascular risk factors –Laboratory tests (glucose, lipids) –Medication Face-to-face interviews with practitioners Eldridge et al (under review)

46 School of Nursing and Midwifery Wellbeing in Kent – “making a difference” ‘Making a difference’ was an emergent theme from practitioner interviews –“…it has flagged up a massive deficit within out clients with some having not had physical interventions for a number years. A lady I assessed hadn’t had a smear for 20 year!” –“…I have welcomed the programme as it recognises the need to provide health promotion activity to a client group where this can be overlooked, falling between services of secondary and primary care” –“I am pleased about running the group and working with others getting the project off the ground has been really enjoyable” –“In fact we are cooking a healthy fry up this week! (i.e. Grilling not frying, including lots of veg and fresh fruit)…” –“…high blood sugar, hypertension, obesity, polypharmacy and sexual health problems all of which I have been able to refer to appropriate services”. –“…I have discovered a number of serious conditions including hypertension, raised cholesterol and recently two inpatients have been diagnosed with diabetes…” Eldridge et al (under review)

47 School of Nursing and Midwifery Outcomes of the programme Enrolled 754 Attended 1580 WellBeing sessions –Mean of 2.1 sessions (half the programme) –159 completed the programme Eldridge et al (under review)

48 School of Nursing and Midwifery Effect on the cohort… None at all Eldridge et al (under review)

49 School of Nursing and Midwifery In those patients that completed the programme Eldridge et al (under review)

50 School of Nursing and Midwifery Sub-group analysis of Wellbeing completers N=159;  2=126.01; df=4; p<0.01 Eldridge et al (under review)

51 School of Nursing and Midwifery Adherence, adherence, adherence

52 School of Nursing and Midwifery Learning… Keep it simple Set standards that can be performance managed Competence of practitioners

53 School of Nursing and Midwifery A different model: the Health Improvement Profile (HIP) Keep it simple stupid!

54 School of Nursing and Midwifery The process of developing the HIP

55 School of Nursing and Midwifery The Health Improvement Profile (HIP)

56 School of Nursing and Midwifery The Health Improvement Profile (HIP) 1 A RISK ASSESSMENT tool for physical health Nurses can be trained to be competent in using the HIP is three hours The physical health of all patients can be profiled A HIP for every patient once a year Enables [nudges] nurses to plan care/make appropriate referrals Guides nurses to evidence based interventions Bridges communication between primary and secondary care 1. White J. et al (2009) Journal of Psychiatric and Mental Health Nursing

57 School of Nursing and Midwifery The HIP process… HIP Plan care Implement care

58 School of Nursing and Midwifery

59 HIP case series 1 31 patients with schizophrenia Nurses in routine care trained to use the HIP 189 physical health issues –6.1 per patient Individualised (evidence based) care and treatment was planned based on individual profiles 28 interventions were used –Providing advice, promoting health behaviour change, performing an ECG, referral to professional colleague

60 School of Nursing and Midwifery The Health Improvement Profile Ongoing research –Northampton (Shelia Hardy) Nurse practitioners using the HIP to review and jointly plan care for all patients on the Trust SMI register –Scotland, Edinburgh (Hugh Masters) Qualitative study of patients experiences of physical health care –Scotland, Lanarkshire (Francis Schule) HIP 100 case series

61 School of Nursing and Midwifery Just finished developing the eHIP

62 School of Nursing and Midwifery Impact 10 NHS Trusts in the UK are using the HIP/eHIP

63 School of Nursing and Midwifery Key points Life expectancy is getting worse not better We need to turn the tide We CAN make a difference –Keep it simple and stick with it! TIME FOR ACTION

64 School of Nursing and Midwifery Physical health and severe mental illness: time for action Richard Gray RN PhD Adjunct Professor of Mental Health Nursing NUI Galway, Ireland e: w:


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